Neurological Assessment Flashcards
Sensitivity
Proportion of times a method correctly identifies an abnormality as being present (true positive).
Specificity
Proportion of times a method correctly identifies an abnormality as being absent (true negative).
Validity
How well the test measures what it is intended to measure. (accuracy)
Intra-rater reliability
The consistency of results obtained by a single examiner over several trials.
Interrater reliability
The consistency of results obtained by multiple examiners.
What is the acronym for measuring cognitive function and what does it stand for?
MR. CLOCK: Memory, Reasoning, Consciousness, Language, Orientation, Calculation, Knowledge
Receptive (Wernicke) aphasia
pt. has difficulty comprehending language, but can produce spoken language
Expressive (Broca) aphasia
pt. has difficulty producing spoken language, but can comprehend language
Lateral Corticospinal Tracts
- descending
- voluntary motor control of contralateral side
- decussates at medulla
Dorsal Columns
- ascending sensory
- conscious discrimative touch, pressure, vibration, and proprioception on contralateral side
Lateral Spinothalamic Tract
- ascending sensory
- pain and temperature
- crosses at level in spinal cord
Posterior Spinocerebellar Tract
- ascending sensory
- unconscious sensory info from LE to cerebellum
- info from muscle spindles, GTO, and joint receptors
- no decussation
Posterior Spinocerebellar Tract Lesion
all lesions ipsilateral because it does not cross
Lateral Corticospinal Tract Lesions
1 hemisphere: -contralateral loss of voluntary muscle control -spasticity distally below level of lesion -hyperactive reflexes Internal capsule: -contralateral spastic paralysis -hyperactive reflexes unilateral lesion in brainstem above decussation: -contralateral spastic paralysis
Dorsal Column Lesions
Hemi-lesion in brainstem (above medulla):
-contralateral sensory loss
Lateral Spinothalamic Tract Lesion
unilat. lesion in postcentral gyrus:
-contralat. sensory loss
Hemi-lesion of brainstem:
-contralat. sensory loss
Hemi-lesion in SC:
-at lesion level-bilat sensory loss
-below lesion-contralat. sensory loss
Complete severance in SC:
-bilat loss of sensation of pain & temp. below level
Upper Motor Neuron (UMN) Lesion Location
Within brain and spinal cord; UMN lesions affect CNS
Lower Motor Neuron (LMN) Lesion Location
Within spinal nerve roots and peripheral nerves; LMN lesions affect PNS
Upper Motor Neuron (UMN) Lesion Signs
Signs: weakness, increased reflexes, increased tone
Lower Motor Neuron (LMN) Lesion Signs
Signs: weakness, atrophy, fasciculations, decreased reflexes, decreased tone
Hypotonia
Pathological decrease in muscle tone; little to no muscle resistance especially when stretched (i.e. Down syndrome, CP, some PNS diseases)
Hypertonia
Pathological increase in muscle tone; increased muscle resistance especially when stretched (i.e. CVA, TBI, SCI)
Spasticity
Resistance to passive motion is rate or velocity-dependent; the faster a limb is moved, the greater resistance is felt
Clonus
Rapid cycles of back-and-forth reflexes (essentially, brain does not “know how” to organize these movements)
Babinski’s Test/Sign
Tests for pathological cutaneous reflex of foot; positive if toes extend and splay when plantar aspect of foot is stroked from lateral calcaneus towards toes and medially across metatarsals
Hoffman’s Test/Sign
Tests for dysfunction of corticospinal tract especially when cervical spine is compressed; positive if thumb flexes and adducts and if fingers flex when third distal phalanx is flicked
Cranial Nerve Screen
I: Smell coffee
II: Read eye chart, check peripheral vision
III: Dilate pupils, follow penlight
IV: Look inferiorly
V: Light touch to face, jaw MMT, jaw jerk reflex
VI: Look laterally
VII: Make facial expressions, taste food
VIII: Feel and hear tuning fork, balance with eyes closed
IX/X: Check gag reflex/swallowing, practice speech
XI: Trapezius and sternocleidomastoid MMTS
XII: Stick out tongue
Eye Muscles and Primary Functions
Lateral rectus: moves eye laterally
Medial rectus: moves eye medially
Superior rectus: moves eye superiorly
Inferior rectus: moves eye inferiorly
Superior oblique: moves eye inferiorly/medially
Inferior oblique: moves eye superiorly /medially
Muscles Involved in Facial Expression
Frontalis, obicularis oculi, zygomaticus major, obicularis oris, platysma
Causes of Cerebellar damage
CVA, Head trauma, alcoholism, metastatic tumors, chemotherapy, MS
Global signs of cerebellar dysfunction
Ataxia, Tremor, Hypotonia, Dysarthria, Deviations in eye control
Ataxia
volitional movements that lack a smooth trajectory and fine motor control = uncoordinated movements
Intentional Tremor
begins & increase as limb reaches a target during volitional movement
Postural Tremor
affected by the head or trunk position
Dysarthria
Poor control of word formation - unable to coordinate muscles associated with speech
Deviations in eye control
Ex - nystagmus, lack of smooth pursuit, saccades, delayed initiation of eye movements
Truncal Ataxia
Wide-based gait, staggering gait with variable starts and stops, lateral deviations, unequal step lengths
Hemispheric cerebellar disorders present with changes in:
UE/LE muscle tone, diminished reflexes, uncoordinated voluntary movement of ipsilateral limbs, dysarthria, disequilibrium, abnormal eye movement
If you suspect cerebellar dysfunction, perform….
1 UE test, 1 LE test, and 1 unsupported stance or gait test
What are the 3 tests used to see limb coordination in cerebellum dysfunction?
Finger-to-nose test, Heel-Shin test, and Diadochokinesia
Finger-to-nose test
- have the patient touch your finger then back to their nose
- time how long 5 reps take
- Normal = smooth precise movements
Heel-Shin test
pt slide heel along shin maintaining contact between heel and leg
Dysdiadochokinesia
Inability to perform alternating movements of the extremities
Upper Extremity Tests
Rapid Alternating Movements, finger opposition, finger-to-nose, finger-to-clinician’s finger
Cerebellar Rebound
-pt sitting with arms straight out in front of them. The examiner pushes downward on both arms.
-Normal: pt’s arm will move downward toward the floor slightly without going past horizontal
Lesions: Rebounding = inability to stop motion quickly. Arm moves down toward floor then up past horizontal, and downward again before stopping
Lower extremity tests
Heel to shin, toe to clinician finger, toe tapping, Standing/walking tests
Tandem Walking
- Normal: pt up to 60 y/o should be able to walk 20 steps without losing balance
- Lesions: demonstrate loss of balance or excessive arm and trunk movements
List and describe the 3 sensory system used in ambulation.
- Visual - light patterns, obstacles, surface changes, things in the environment, ect
- Somatosensory - info from skin, muscle, tendon, joint receptors relative to body parts and surface
- Vestibular - position and movement of head relative to gravity and inertial forces. (Peripheral - semicircular canals and otolithic organs. Central - CN VIII, vestibular nuclei, ect)
Order of balance strategies from least to greatest.
Ankle, Hip, Stepping
Static standing balance tests
Romberg eyes open/closed, Sharpened Romberg eyes open/closed, Single-Limb Stance eyes open/closed
Romberg Test
pt stands with feet parallel and together for 30 seconds and the therapist judges the amount of sway
Sharpened Romberg
pt stands with feet in tandem for 30 seconds and the therapist judges the amount of sway
Anterior Spinocerebellar Tract
Carries unconscious sensory info from LE muscle spindles, golgi tendon organs, and joint receptors to cerebellum
Decussates in lumbar spinal cord
Anterior Spinocerebellar Tract lesions
1 hemisphere lesion= contralateral proprioceptive loss
Superior cerebellar peduncle lesion= contralateral proprioceptive loss
Hemi-lesion in spinal cord at lesion level= bilateral proprioception loss
Hemi-lesion in spinal cord below lesion= contralateral proprioception loss
Complete SC severance= bilateral LE proprioception loss
Descending Vestibulospinal Tracts
Facilitates extensor tone, antigravity (extensor) muscles, and postural muscles
DOES NOT DECUSSATE
Vestibulospinal Tract Damage
Decerebrate rigidity (spastic extension of both UE and LE) Much poorer prognosis than decorticate
Nerve root compression
Causes dermatomal sensation loss
Can be due to: narrowing of vertebral foramen, facet hypertrophy, herniated disc
Peripheral Nerve Injury
Presentation: non-dermatomal pattern
Caused by: local compression, crush injury, surgical incision
SCI
Typically damages several or all ascending and descending nerve tracts
Varied somatosensory and motor dysfunction from minor to complete
Tumor
Affects somatosensory and motor tracts depending upon location
Brain lesions
Result of CVA, TBI, or tumor
Affects somatosensory and motor function if in thalamus and parietal lobe
Presentation: unilateral somatosensory deficits opposite lesion unless both hemispheres of brain involved
Nonselective Nerve Damage
Bilateral and symmetrical somatosensory loss that does not follow and known nerve pathway
Stocking glove distribution varying from minor to extensive loss
Diabetes Mellitus
Body fails to produce or adequately use insulin
MS
Progressive autoimmune disease that demyelinates CNS axons
Slows/blocks motor and sensory paths
Numbness and tingling= 1st signs and symptoms
Guillain-Barre Syndrome
Non-progressive autoimmune disease affecting myelination of PNS axons
Slows/blocks neural connection in sensory or motor paths
Hansen’s Disease
Chronic bacterial infection (leprosy)
Primarily affects peripheral nerves
1st sign in 90%= numbness in distal extremities
Lyme Disease
Inflammatory disease caused by dear tick bite
Loss of sensation in arms and legs can develop rapidly
Alcoholic Neuropathy
Sensory loss appears first in stocking and glove pattern as result of axonal degradation
Differential diagnosis difficult due to denial
Somatosensory Screening
Inform pt of purpose and how it will go
Compare bilaterally and distal to proximal
Vary pace and attempt to map areas of loss
Light Touch testing
Tests dorsal columns (Spinothalamic crude touch)
Use cotton, gauze, or finger and gently rub over skin
Protective sensation
Tests Spinothalamic and Dorsal columns
Use monofilaments
Sharp/Dull Pain
Tests Spinothalamic Tract
Use safety pin or something sharp and poke them throughout dermatomes
Vibration
Tests dorsal columns
Use tuning fork and touch to skin in various areas throughout extremity
Have pt tell you when they can no longer feel vibration (should be 30-60 sec)
Temperature
Tests Spinothalamic tract
Can be omitted if pain sensation is intact
Use 2 tuning forks or test tubes with one hot and one cold and apply to different areas
Have pt tell you which side and whether it is hot or cold
Position Sense
Tests dorsal columns
Use minimal stabilization and have pt close eyes and tell you if joint/limb is in up or down position
Joint Space Test (Contralateral Mirroring)
Have pt close eyes and put uninvolved limb into a position, then have patient copy position with involved limb
Not useful if pt has bilateral involvement
Finger-to-Nose Test
Ask pt to close eyes and lightly touch one finger, then have pt take that finger and touch their nose
Discriminative sensation
Tests dorsal columns and portions of cerebral cortex
Combination of stereognosis, graphesthesia, 2-point discrimination, and point localization
Stereognosis
Have pt close eyes and hand them common items and identify what item they are holding
Graphesthesia
Use blunt end of pen or finger and write letters/numbers on pt skin and have them identify what letter or number it was
2-point discrimination
Use tool and touch pt finger simultaneously with distance getting closer and closer
Normal= 5mm on finger pads
Point Localization
Have pt close eyes, lightly touch skin, have pt open eyes and point to where you touched
Repeat on both sides and throughout body
When to Test
If pt C/o Sx consistent with neuro involvement, start with light touch and pain, then move to other portions of exam if normal
If ABNORMAL, do more neuro testing
Always perform light touch
No need to test further if no deficits or if pt has condition that would not affect nervous system
